Adoption of New Technologies for Multiple Sclerosis Rehabilitation

Podcast Transcript

Dr. Alex Rae-Grant:  Neuro Pathways, a Cleveland Clinic podcast from medical professionals exploring the latest research discoveries and clinical advances in the fields of neurology and neurosurgery. Welcome to another episode of Neuro Pathways. I'm your host, Alex Rae-Grant, neurologist in Cleveland Clinic's Neurological Institute. As part of our exploration of neurological care, today we're talking about adopting new technologies for multiple sclerosis rehabilitation. I'm very pleased to have Dr. Francois Bethoux to join us for today's conversation. Dr. Bethoux is the chairman of the Department of Physical Medicine and Rehabilitation, medical director of Cleveland Clinic's Arts and Medicine Institute, and director of rehabilitation services in the Mellen Center for Multiple Sclerosis in Cleveland Clinic's Neurological Institute. Francois, welcome to Neuro Pathways.

Dr. Francois Bethoux:   Thank you for having me.

Dr. Alex Rae-Grant:  So knowing that you're not native to Cleveland, let's start off by telling our listeners a little bit about yourself. How did you find your way to Cleveland Clinic?

Dr. Francois Bethoux:  Well, to tell you the truth, I heard about these wonderful winters that are prevalent around the Cleveland area. But more seriously actually, I did a year of research about at Metro Health Medical Center in Cleveland, and then I kind of caught the bug of possibly staying in the area. So I interviewed, and eventually I started working at the Cleveland Clinic. It's as simple as that, and then I stayed on and it's been 22 years now.

Dr. Alex Rae-Grant:  So for those Francophiles in the audience, originally where are you from?

Dr. Francois Bethoux:  I'm from the middle part of France. The city is called Lyon. Unfortunately, it doesn't have a bad reputation, it just doesn't have much of a reputation, which is totally undeserved. It's actually the gastronomy capital of France.

Dr. Alex Rae-Grant:  I hear it's very nice. So let's turn back to it to what we're actually talking about today, advances in technology for MS rehabilitation. Can you tell us generally how MS rehab has evolved over the last decade, and specifically how we're adopting newer technologies?

Dr. Francois Bethoux:  MS rehab has had a long journey, I would say. At first, probably two or three decades ago, we were advising our patients against doing any exercise because we thought that would possibly trigger relapses or exacerbation of MS. And then came studies showing that actually exercise has a positive impact on people with MS, and then that triggered the whole path of MS rehab with physical occupational therapy, the use of devices, traditional devices and now more recently the use of more technologically cleared advanced devices. And as you know, technology is all around us and sometimes we think it's ruling our lives. I think it opens avenues for people with disabilities, including people with MS who are suffering from the consequences of the disease.

Dr. Alex Rae-Grant:  So let's maybe talk about one early technology that you guys developed, the Hip Flexion Assist Device, and it sort of set the tone for adopting new technologies. Can you tell us a bit about that and how it's been beneficial for MS patients?

Dr. Francois Bethoux:  Certainly. This was actually the brainchild of one of our physical therapists, Matt Sutliff. He had the idea of designing basically a bungee cord with a belt to help people lift their leg. In MS, it's common to have weakness in what we call the hip flexors, and when you have a weakness in the hip flexors, it's very hard to actually advance the whole leg and make steps. And we always talk about foot drop, which is also a problem that is more at the ankle level. But actually, if you can't really lift the leg at the hip, then the whole limb just doesn't want to advance. And we didn't have any devices for that. So based on this idea, we worked with an orthotist, somebody who had the engineering background, and then did clinical studies that showed really some benefits in some people. It's the same with every technology. It can be great for some people, not so great for others and for again others, it could be something they're not interested in or something that's not going to work for them, possibly work against them in a way, cause some side effects, some adverse effects.

But this device is to me an example of a low cost device that is very simple that can be applied by the person him or herself and then worn during activities and then basically taken off when it's not needed anymore, and it's currently available with prescription. And to me, the low cost aspect of it is very important. People with MS, people are with almost any chronic disease, have a lot of medical expenses and other expenses related to the consequences of their disease. And so I don't want to add too much to their financial burden, and I think this device has a great value because of the impact it can have on walking yet with a very reasonable cost.

Dr. Alex Rae-Grant:  Well, changing gears a bit, music was an older technology and it's still a great technology, and I know you have a personal interest in that. Can you describe as medical director of the Arts and Medicine Institute, how music is being incorporated into the overall treatment plan for some MS patients?

Dr. Francois Bethoux:  Before I start talking about this, my disclaimer is that I am not a musician. I used to play the piano, but that was high school, basically. But I've had this interest in applying the arts in medicine. Of course, I'm not the only one with this interest, but when I had the opportunity to become the medical director of the Arts and Medicine Institute, I launched research projects or I continued with the research projects that I had been doing for about eight years, nine years, that basically consist of applying rhythmic music to improve how people with MS walk.

So it's along the same lines of the Hip Flexion Assist Device. What can we do to help people with MS? The vast majority of people with MS have difficulty walking to various degrees. It could be impossibility to walk or catching your toes or having difficulty going a long distance. And it turns out that in other disorders, such as Parkinson's disease, rhythmic music has been used successfully to enhance walking, so I started using it in MS and we've had some positive results. Again, it's a low cost technology. All you need is to have access to music with a rhythm and a device to play it in your ears, and then we had to figure out a way to make it work for people so that they could use to enhance their exercise routine. So the idea is to use that rhythmic music to enhance the exercise routine so that at the end, you get a better outcome, a better result from the exercise.

And our latest study shows signals in that direction. The people who were just doing walking exercise without music didn't do as well as people who used the music when they were doing their exercise. Of course, in addition to that, music can have an emotional impact that we could use to entice people to do the exercise. It's more enjoyable and you can do it more, and if you do more of the exercise, then you get better results just from the fact of a higher volume of exercise. There are many aspects to the impact on music that we haven't explored yet.

Dr. Alex Rae-Grant:  So there have been some recent developments in computer-assisted rehabilitation. Do you want to tell our listeners a bit about the CAREN system and how we're using it in rehab and MS at the Mellen Center?

Dr. Francois Bethoux:  We're very fortunate to have the CAREN system at our disposal to treat some of our patients who come for physical therapy. Basically, the system condenses in one place many devices and motion sensors that would be available otherwise in separate pieces if you wish, but by putting them together, it allows people to work or exercise in an environment that can be closer to real life conditions. For example, if I exercise in the gym, I get an opportunity maybe to walk on level ground or maybe on an incline or maybe do stairs, but the CAREN system has a six degrees of freedom platform that can mimic the rocking of the boat or up or down a slope, for example.

It has motion sensors that are integrated with the motion system so that the system can react to what people do. For example, if somebody leans to the left, it can be programmed that on the screen, the person will see themselves or maybe a boat or maybe another piece of equipment veer to the left as well. So it creates its own virtual environment. There's 180 degree screen, and basically it's almost like being inside a video game if you wish.

Dr. Alex Rae-Grant:  So we know that exoskeletons have been used in spinal cord injury for a while and sometimes post-stroke rehab, but you've launched some novel trials for use in multiple sclerosis. Can you tell us a bit about that?

Dr. Francois Bethoux:  I've been very attracted to the exoskeleton technology. If you have a chance to look at videos on the internet, it has a slightly futuristic feel to it and actually, the word has been around that the Army was looking at devices like these to enhance the powers of their soldiers, for example. But in rehabilitation, I think there is untapped potential. The idea with the exoskeleton is to have a robotic brace, a brace that encapsulates the legs up to the hips, up to the pelvis, and then motors that can activate the joints of the device to help the joints of the leg move and a complex software that can respond to what sensors can catch. If somebody intends to make a step, then they will move their body in such a way that if the sensor catches it, then it will trigger a step assisted by the device.

It's a way to, again, have a machine that interacts with the person, can interact with the environment. It has safety features to prevent falling, for example, and can enhance the person's abilities. So if that person has weakness in the legs, then the machine can do some of the walking for that person. If they become more and more tired as they walk a longer distance, the machine can take over more and more, or vice versa. If they become stronger as they walk more, then the machine will provide less assistance. For example, from session to session, if with training the person becomes more adept at walking, then we can provide less and less assistance until they can just do their training without the machine.

The idea is the machine is really not the end of it all and I think that's really what I've learned through research with almost any technology. The technology is an enabler or an enhancer. It's something that allows to perform exercise, rehabilitation or some functions of life in an easier way. It doesn't replace it. It just enhances, but it can enhance it in such a way that makes a meaningful difference to the person.

And so the exoskeletons, right now, we're in the middle of conducting a pilot study of five people with MS. There have been more studies of the exoskeleton in people with spinal cord injuries or stroke, as you said, but in MS, we were aware of only one published small study, so we studied from scratch and try to understand how this device could be integrated into their rehabilitation to hopefully provide better outcomes with walking, better outcomes than doing the exercise on their own, possibly even than doing the exercise with a physical therapist one-on-one. And so that's what we exploring right now and we hope that this study will provide some preliminary results that will allow you to run a larger trial.

Dr. Alex Rae-Grant:  What other things do you see on the horizon for MS rehabilitation? Are there other places that we may be going in the next few years?

Dr. Francois Bethoux:  One aspect I'm fascinated by is the application of consumer technology to people with MS or with other disabilities, so all these smart phones and tablets and these home assistants now are invading our space in our lives can actually be used probably with some adaptation or with the help of a professional to understand how it can really help the person, but you can imagine somebody who has limited mobility in their home being able to activate lights, to open a door, to start an oven that can really enhance their abilities.

Also, we know now that we can use the sensors in the smartphones and tablets to capture motion or other information, and there's some work that's ongoing and the Cleveland Clinic right now to use software on a tablet or apps basically on a tablet to measure neurologic function. And you can imagine that then we could monitor hand dexterity, balance, the ability to walk, possibly memory and cognition in the person's home between visits to the provider so that we can have a better idea of how they function in their home, but also how it evolves between two visits, because right now we just have snapshots during the visits. So all of this to me is fascinating, and again, accessible to most people at a low cost because it's not medical technology. It's consumer technology that's adapted for medical purposes.

Dr. Alex Rae-Grant:  I'd like to come back to one thing you said about the Hip Flexion Device, which is that it's a fairly simple technology and sometimes in MS rehab, simple tweaks may make a big difference to an individual. Something focused on tripping, something focused on the right kind of aid for gait, things like that may make a huge impact, and we don't necessarily have to use technology all the time.

Dr. Francois Bethoux:  I would agree. I would agree with that statement. I think it depends how you define technology because you could say a simple brace is actually assistive technology. But if you think of more advanced technology, I think ease of use is an important part. Obviously, access which includes cost and the availability of devices play into that, so sometimes the simple solutions work the best for people. I've had some patients who actually design their own technology and I said, "Oh yeah, you have that Hip Flexion Device." "Well, I made my own and it works much better. Look at my video on the internet."

Sometimes it's true that these simple solutions, homemade solutions work for that person. Again, there's a place for everything, but we need to do some thinking ahead and along the way. One example I often cite is the example of a robotic device paired with a treadmill that has been studied in several clinical trials in MS. And in the end, the message on efficacy and particularly on the superiority of this very expensive device generally requires two therapies to work with the person compared to working one-on-one with a very skilled therapist. It seems that they came out about even, so again, the question is what is the technology's place, and I don't think we have all the answers right now.

Dr. Alex Rae-Grant:  Very good. Any other major takeaways to make?

Dr. Francois Bethoux:  I have to confess as I'm getting older, I don't know if I'm getting wiser, but I'm getting more cautious. I used to see technology as the end of it all, again, as there is definitely a future where technology would take over almost rehabilitation and almost replace human rehabilitation specialists. And now I've realized that actually, there's a potentially large place for technology in MS rehabilitation and in the lives of people with MS, but we have to understand in partnership with the people and with MS and their families how that can best help them. It doesn't just come and then as if by magic takes over and makes life perfect. We've realized that with our common uses of technology, and I think it's the same when people have consequences of MS, so that we would be my take home message. A lot of hope, but measured hope. We really need to know how to make it work and listen to all the stakeholders to understand how to make it work.

Dr. Alex Rae-Grant:  Well, Francois, thank you so much for joining us. I really appreciate your time and insights.

Dr. Francois Bethoux:  It was my pleasure to talk with you.

Dr. Alex Rae-Grant:  This concludes this episode of our Neuro Pathways podcast. You can find additional podcast episodes on our website, ClevelandClinic.org/neuropodcast. Subscribe to the Neuro Pathways podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website, ConsultQD.ClevelandClinic.org/neuro, or follow us on Twitter at CleClinicMD, all one word. That's C-L-E Clinic MD on Twitter. Thank you for listening. Please join us again soon.